Surveillance of infection in neonatal intensive care units

Monitoring infection rates is increasingly regarded as an important contributor to safe and high quality health care, especially in intensive care settings. Early-onset neonatal sepsis rates are an important indicator of ante- and intra-partum care, especially as medicalisation of obstetric practice increases. However, surveillance of late-onset neonatal sepsis is required to monitor the quality of Neonatal Intensive Care Unit (NICU)-related care. Infection surveillance on NICUs presents a number of unique challenges, including defining infections, the preponderance of coagulase-negative staphylococci as both pathogens and commensals, and allowing for the influence of important risk factors. Ideally an infection surveillance programme should permit benchmarking of infection rates, and multi-centre programmes have been reported to decrease the incidence of healthcare-associated infections on NICUs. However, further research is required to identify the most clinically- and cost-effective means of surveying NICU-acquired infections before a national programme can be implemented. Until then, considerable value can be obtained from local infection surveillance.     

加拿大新生儿重症监护病房早产儿机械通气期间麻醉镇痛药和镇静剂应用趋势的回顾性研究

早产儿气管插管有创机械通气可引起患儿不适,但是否导致疼痛仍存有争议。已发表的荟萃分析显示,早产儿机械通气期间应用麻醉镇痛药并未减轻患儿疼痛。因此,不推荐对新生儿重症监护病房（NICU）机械通气早产儿常规应用麻醉镇痛药和镇静剂。假设目前加拿大NICU早产儿机械通气过程中麻醉镇痛药和镇静剂的使用呈下降趋势。该研究回顾性分析了2004~2009年间出生胎龄 < 35周、需要有创机械通气 > 24 h的早产儿接受镇静剂和麻醉镇痛药使用的趋势。入院时处于濒死状态、先天畸形、需要外科手术（除外眼科激光手术）、坏死性小肠结肠炎、胸腔置管引流或孕母有麻醉药品滥用史的早产儿不纳入该研究。根据早产儿是否接受麻醉镇痛药（如吗啡、芬太尼、美沙酮、舒芬太尼、杜冷丁、阿芬太尼和可待因等）或镇静剂（如水合氯醛、咪达唑仑、劳拉西泮、苯巴比妥、戊巴比妥、氯胺酮和丙泊酚）以及早产儿胎龄（胎龄 < 29周和胎龄29~34周）分组,采用Cochrane-Armitage趋势分析方法评估早产儿麻醉镇痛药和镇静剂的应用趋势。5 638名早产儿符合纳入标准,其中2 169名（38.5%）应用了麻醉镇痛药,897名（15.9%）应用了镇静剂,722名（12.8%）同时接受了麻醉镇痛药和镇静剂治疗。最常用的麻醉镇痛药是吗啡（62.2%）和芬太尼（63.8%）;最常用的镇静剂是苯巴比妥（44.9%）和水合氯醛（44.2%）。镇静剂的使用在胎龄 < 29周和胎龄29~34周两组早产儿中均呈明显的下降趋势（P < 0.01）;但胎龄 < 29周组早产儿麻醉镇痛药的使用显著增加（P=0.03）,胎龄29~34周组麻醉镇痛药的使用未发现明显的趋势变化。 经历有创机械通气的新生儿有疼痛感受吗?机体会产生应激反应吗?据成人有创通气的研究结果报道,约25%的ICU患者出院后仍记得在ICU住院期间的感受,并承认经历气管插管和有创机械通气的过程是很痛苦的。然而,现实中很难区分患者的疼痛感受是由于ICU住院期间的有创通气引起,抑或是因在ICU住院期间躯体的疾病或其他因素所致。同理,对于住院期间早产儿皮质醇水平的升高,是由于疾病的严重程度或因机械通气引起的疼痛和/或应激所致同样很难鉴别。查阅大量文献发现,有创机械通气期间麻醉镇痛药或镇静剂的使用并没有减轻患者的痛苦,然而药物潜在的不良反应却令人担忧。但目前在NICU住院早产儿有创机械通气过程中,给患儿应用麻醉镇痛药或镇静剂仍然是很普遍的现象。 该研究数据来自于加拿大新生儿协作网,该协作网覆盖了加拿大全国范围内30家三甲医院。样本量大,数据收集方法有效、可靠,这是该研究的主要优势。其主要不足在于机械通气早产儿没有明确的应用镇静或麻醉镇痛药物的指征,一些分析只能是从现有的数据外推。此外,该研究早产儿上机过程中其他非药物镇痛替代措施的应用,也可能会高估或低估麻醉镇痛药/镇静剂的作用。其他的影响因素还包括：缺乏疾病的严重度、上机时间以及麻醉镇痛/镇静药物应用的评估依据,以及研究资料未能收集到上机过程中环境因素或非药物干预措施减轻患儿不适/应激/疼痛的数据,所以不能对机械通气过程中麻醉镇痛/镇静剂使用趋势做出更为深入的解释。目前,令人担忧的是,机械通气过程中接受阿片类药物镇痛的早产儿是受药物不良反应影响的高风险人群,而这些药物在这个群体中的应用又呈现增加趋势;但如果对NICU住院早产儿经历的疼痛和应激不予管理,也会对其神经系统发育产生近期和远期的不良影响。因此,在临床实践中,必须对早产儿的疼痛采用量表进行评估,根据循证医学指南指导麻醉镇痛药和镇静剂的应用,从患儿舒适的角度制定治疗和护理方案。 尽管麻醉镇痛药和镇静剂可能的潜在不良反应的否定证据也逐渐增加,但加拿大新生儿医师仍然担忧机械通气早产儿连续应用麻醉镇痛药和镇静剂以及肌松剂的不良反应。用非药物的措施减轻机械通气患儿的不适/应激/疼痛的研究日益增多并受到广泛的关注,且有巨大的应用前景。一些在研的、旨在减轻早产儿上机过程中经历的中等程度的疼痛/应激、同时又尽可能限制药物不良反应并考虑到对患儿远期神经发育影响药物的研究已经得到批准。另外,住院新生儿经历的慢性疼痛也引起了许多学者的重视,且也成为一个新兴的研究热点,需要学者们开展更深入的研究。 小结：加拿大NICU胎龄 < 35周的机械通气早产儿镇静剂的使用呈下降趋势,临床应用遵循了循证医学的证据,但麻醉镇痛药的使用在胎龄29~34周早产儿组并没有变化,且超低胎龄早产儿组（胎龄 < 29周）麻醉镇痛药的使用呈增加趋势。加拿大的新生儿医师在决定是否给有创机械通气的早产儿使用麻醉镇痛/镇静剂时是慎重的,但该研究结果显示加拿大NICU早产儿机械通气期间麻醉镇痛药的使用并没有呈下降趋势,其原因尚需进一步深入研究。     

中国新生儿重症监护病房中实施家长参与早产儿住院期间综合管理与常规护理的平行对照研究

目的探讨在中国NICU实施家长参与早产儿住院期间综合管理（FICare）的可行性。方法以平行对照设计试验方案,对在中南大学湘雅三医院NICU中符合FICare组纳入标准的早产儿行FICare模式干预（建立FICare组医护团队,NICU改造,掌握六步洗手法、脐带护理、口腔护理、留置胃管管饲、婴儿洗澡、袋鼠式搂抱、称体重、皮肤护理、母乳喂养等）,选择同期NICU中符合对照组纳入标准的早产儿以常规护理模式干预。主要观察住院时间,次要观察体重增长速度、开始胃肠内喂养时间和达到全胃肠内喂养的时间、母乳喂养率、院内感染率、总氧疗时间、出院30 d内再次入院率和纠正胎龄37周时NBNA评分;附加观察FICare组家长出现在NICU后FICare医护团队工作期间心理压力、医疗费用、研究期间的医疗纠纷投诉率、病房额外开支、实施FICare后与前1年同期NICU的不良事件数量等。结果FICare组和对照组分别纳入30和60例,两组基线具可比性。FICare组和对照组NICU住院时间分别为（25.9±7.1）d和（29.2±6.0）d,差异有统计学意义（P=0.035）。两组开始胃肠内喂养日龄、院内感染率差异无统计学意义;FICare组与对照组比较,达全胃肠内喂养时间较快、母乳喂养率较高、体重增长速度较快、总的氧疗时间较短、出院30 d内再次入院率较低、纠正胎龄37周时NBNA评分较高,差异均有统计学意义。当FICare组家长出现在NICU,6/6名护士均在工作期间感觉心理压力增加）,护士自愿报名参加FICare课题组却增加了7人,没有医疗纠纷投诉, 总医疗费用减少,实施FICare后与前1年同期相比NICU的不良事件数量下降（每月2.2 vs 4次）。结论在中国NICU实施FICare具可行性,继续开展FICare的后续研究是安全的,但医护人员工作压力和NICU的额外支出有所增加。     

Risk factors for nosocomial sepsis in newborn intensive and intermediate care units

Abstract A multicentre prospective study was performed to estimate the incidence of hospital infections and to identify the most relevant risk factors for sepsis in a large and unselected population of high-risk newborns. The study involved 49 neonatal intensive care units and 17 neonatal intermediate care units in Italy. Newborns were followed up from admittance to the units until discharge. Data on demographics and clinical characteristics, exposure to the principal invasive procedures, and onset of infectious complications were prospectively collected. Only infections developing after 48 h from admittance to the unit were recorded. A multiple logistic regression was performed to identify which factors were independently associated with sepsis. Among the 8263 newborns included in the analysis, the incidence of infected newborns was 14.4 per 100 newborns and 0.9/100 days of stay. The incidence of infections was 19.1/100 newborns and 1.2/100 days of stay. Sepsis represented 15.4% of all infections (incidence 2.9/100 newborns and 0.2/100 days of stay). The following factors were independently associated with sepsis: umbilical catheterization, both through the vein and the artery for more than 5 days; mechanical ventilation for more than 5 days; necrotizing enterocolitis; birth weight equal to or less than 2500 g; nasogastric tube; total parenteral nutrition; and transfer from other hospitals. Umbilical catheters accounted for the highest proportion of sepsis (62%), followed by arterial catheters (31%), nasopharyngeal cannulae (26%), tracheal cannulae (20%), and nasal cannulae (20%). The population attributable risk for the other procedures was less than 10%.Conclusion This study demonstrates that in a large and unselected newborn population, several host factors and invasive procedures are independently associated with an increased risk of sepsis. After adjustment for clinical severity, intravascular catheterization and assisted ventilation were found to be responsible for a considerable proportion of observed sepsis. They shoudl therefore be considered as priorities for interventions, aimed both at reducing unnecessary use and promoting more strict compliance with aseptic practices.     

儿科重症监护病房中影响机械通气成功的相关因素

目的 探讨儿科重症监护病房(PICU)中影响机械通气成功的相关因素。方法 将lll例行机械通气的危重病儿分成治疗成功组与失败组，对其相关因素进行回顾性分析。结果两组患儿在上机前危重病例评分、是否伴有心跳呼吸骤停和(或)休克及并发多系统器官功能衰竭(MODS)等方面差异有权显著意义(P＜0．001)；超过48h的机械通气患儿是否继发呼吸机相关肺炎(VAP)亦有显著意义(P＜0.05)。结论 PICU中影响机械通气成功率的因素主要是原发病的性质及严重程度，并与MODS与VAP有密切关系。     

Risk factors associated with gut and nasopharyngeal colonization by common Gram-negative species and yeasts in neonatal intensive care units patients

Aim

To characterize dynamics of mucosal colonization of neonates by common aerobic Gram negative species and Candida spp. and to identify independent perinatal, neonatal, and environmental factors influencing the colonization process.

Study design

The nasopharyngeal (n = 1145) and rectal (n = 1242) swabs were collected on admission and thereafter twice a week in neonates with risk factors of early onset sepsis (n = 276) admitted within the first 72 h of life. The association between colonization by different microbes and a total of 22 predefined risk factors was assessed using univariate and multiple logistic regression analyses.

Results

Throughout the study about half of the patients had rectal (55.8%) or nasopharyngeal colonization (42.8%) with common Gram-negative microorganisms. Colonization dynamics and risk factors were in general similar for a given bacterial species in both mucosal sites; nonfermentative microbes more often found in nasopharyngeal swabs and Enterobacteriaceae in rectal swabs. All organisms except Escherichia coli were influenced by the duration of intensive care unit stay but other risk factors were species specific, perhaps reflecting their mode of acquisition. While colonization by E. coli and Candida albicans was associated with perinatal factors like term birth, vaginal delivery, and breast milk feeding; colonization by Klebsiella pneumoniae, Enteribacter cloacae, Acinetobacter spp. and non-albicans Candida spp. were mostly determined by hospital environment (treatment unit and period, artificial interventions and their duration) and gestation age ≤ 28 weeks.

Conclusions

The knowledge of risk factor profiles may permit the development of strategies to prevent heavy colonization and subsequent invasive disease in high risk infants.     

Methicillin-resistant Staphylococcus aureus bacteraemia in neonatal intensive care units: an analysis of 90 episodes

Aim: To delineate the clinical features of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia in infants hospitalized at the neonatal intensive care unit. Methods: Episodes of MRSA bacteraemia in Chang Gung Children's Hospital neonatal intensive care unit from 1997 to 1999 were reviewed for incidence, predisposing factors, clinical presentations, treatment and outcome. Results: Ninety episodes of MRSA bacteraemia were identified. The overall rate of MRSA bacteraemia was 1.05 per 1000 patient days during the 3-y period. Most of the patients were premature infants (76%), with prior operation or invasive procedures (39%), had an indwelling intravascular catheter (79%) and exposure to antibiotic therapy (96%). A localized cutaneous infection was found in 53.3% of the episodes. The most common clinical diagnoses were catheter-related infections (54.4%), skin and soft tissue infections (21.1%), bacteraemia without a focus (20%) and pneumonia (16.7%). Metastatic infection occurred in 18% of these infants. Among the patients treated with vancomycin for ≤14 d, 88.7% did not develop any complications, and 11.3% developed a recurrence.

Conclusions: MRSA is an established pathogen in our NICU. MRSA bacteraemia in the neonates predominantly presented as catheter-related infections, and metastatic infections were not infrequently seen. In uncomplicated MRSA bacteraemia, treatment with vancomycin for ≤14 d seems to be adequate.     

Social determinants of health and the neonate in the neonatal intensive care

It is increasingly recognised that social determinants of health such as socioeconomic inequalities, parental education level, addiction behaviors, mental health difficulties and breast-feeding rates all influence immediate and long-term outcomes in neonatal intensive care unit (NICU) graduates. Awareness, recognition and appropriate management of these risks may help alleviate some of these effects. This review looks at various social determinants and their effects on patients and families in the NICU.     

High-flow nasal cannula use for bronchiolitis treatment in French intensive care units: A transversal study

Over the past 10 years, continuous positive airway pressure (CPAP) has revolutionized the prognosis and management of bronchiolitis patients hospitalized in pediatric intensive care units (PICUs). High-flow nasal cannula (HFNC) is emerging as an alternative to CPAP. Despite encouraging results of several clinical and physiological studies, HFNC use remains controversial and its indications heterogeneous. To better define the place of HFNC in severe bronchiolitis respiratory support, we investigated the different ventilation assistance techniques used for severe bronchiolitis over 3 days at the peak of a bronchiolitis epidemic in December 2015. We conducted an observational cross-sectional study in 27 French university hospital PICUs. Fifty-nine patients were included. The results show that HFNC already accounts for nearly half of the respiratory support techniques used for severe bronchiolitis in French PICUs with no significant difference between the CPAP group and the HFNC group of patients.     

Antimicrobial usage in paediatric intensive care units in China

AIM: The aim of the study was to determine antimicrobial usage in paediatric intensive care units (PICUs) in China. METHODS: Data were equally collected from 540 charts of PICUs in the three Chinese tertiary teaching children hospitals in 2006. The data included demographic, clinical data and those on antimicrobial usage and results of microbiological examinations. RESULTS: Of the 540 cases, 524 (94.7%) patients received at least one antimicrobial agent. The main treatment started empirically in 387 (71.6%). The third-generation cephalosporins were the major antimicrobials used in all participating hospitals, accounting for 227 (31%). Bacteria were isolated from 48%, 68% and 59% of the three PICUs. Six common pathogens accounted for more than 75% of the isolated bacteria. The rates of Escherichia coli isolates resistant to cefotaxime were 73.8%, 58.3% and 49.2%, respectively, with the rate being higher in H1 than in H2 and H3 (both p<0.01). CONCLUSIONS: Irrational use of antimicrobials exists in clinical practice of PICUs in China. It is recommended that antimicrobial usage should be guided by bacterial isolation and antimicrobial susceptibility tests in order to select correct antimicrobials and to prevent emergency of drug-resistant strains in PICUs.